More than 60% of non-traumatic lower extremity amputations (LEA) involve diabetes. 65,700 non-traumatic LEA were performed in people with diabetes in 2006, said Dr Sarnarendra Miranpuri. Amputations of the foot, ankle and toe in people with diabetes comprise 70% of amputations, said Dr Miranpuri.

Quoting poetess Susan Jeffries, Dr Miranpuri said "if you always do what you awlays did, you always get what you always got." He was convincingly arguing for collaborative and comprehensive care of people with diabetic foot with the goal to save the limb.

"What we need is an interdisciplinary team for the diabetic foot in the hospital" advocates Dr Sarnarendra Miranpuri. There are many benefits of such an interdisciplinary team for the patient as it reduces time to assess and intervene to improve vascular status and manage wound apart from other treatment outcome gains.

Amputation is a marker of the quality of foot care in diabetes. High incidence of amputation is usually because of higher disease prevalence, late referral, limited resources and inteventionalist approach by treating doctor vis-à-vis an interdisciplinary team approach.

An interdisciplinary team in a hospital or a limb salvage team is central to raising awareness about issues related to limb salvage; and also scale up services related to diabetes care, end stage renal disease (ESRD), venous disease among others.

Diabetes is on the rise. Even in the United States, according to the World Health Organization (WHO), 25.8 million people are living with diabetes (8.3% population). Out of these 18.8 million have been diagnosed and 7 million are yet to diagnosed and cared for.

The latest data shows that China has more people with diabetes than India. A study published in New England Journal of Medicine in 2010 showed that China has 92.4 million adult people with diabetes. However, if diabetes responses in India don’t buckle up, soon the situation will be grimmer in India with again becoming home to largest number of people with diabetes.

"It is a wakeup call for policy makers to take major action on diabetes" said Dr Sarnarendra Miranpuri.

"Diabetes and non-communicable diseases (NCDs) have replaced infectious diseases as major cause of mortality – diabetes has overtaken HIV/AIDS as 3.2 million deaths are attributed to diabetes every year compared to 3 million HIV related deaths" said Dr Sarnarendra Miranpuri.

Diabetes incidence is not only on the rise in developing countries but also in the developed world. "In 2009 only 2 states in US had diabetes prevalence less than 6% with rest of the states in US reporting far higher diabetes rates" said Dr Sarnarendra Miranpuri. Few reasons for this rise in diabetes include lack of healthier options for people with fast food becoming cheaper and more available.

Not surprisingly, in US, the diabetes belt also overlaps with obesity and stroke belt for America, said Dr Sarnarendra Miranpuri.

Speaking about the risk factors, Dr Sarnarendra Miranpuri said that obesity and sedentary lifestyles were found to scale up the risk for diabetes.

In India, young Indians with lower body mass index (BMI) are more susceptible to diabetes compared to Caucasians, said Dr Sarnarendra Miranpuri. India is experiencing a rapidly escalating 'epidemic' of Type II diabetes and coronary heart disease (CHD). This occurs on the background of a characteristic body composition: Indians are thin by conventional criteria (low BMI) but are centrally obese. Recent research suggests that adult Indians have more body fat and lower muscle volumes than white Caucasians, African Americans and other ethnic groups of comparable BMI. Thus, the Indian body composition could be described as adipose but muscle thin. It is also referred to as Thin Fat Indians who have high adipose (body fat).

"Thin fat Indians have high adipose. Thus they have a high risk of diabetes due to epigenetics (fetal programming) and post natal growth of small children. Micronutrient abnormalities and economic development also contributes to the intergenerational amplification of the diabetes because of adiposity (body fat)" said Dr Sarnarendra Miranpuri.

Diabetes also has a massive economic toll – it is projected that by 2025 if we do business as usual, USD 396 billion will be the money spent on responding to diabetes. It makes economic sense as well along with public health benefits to improve diabetes responses on the ground.

Speaking about nervous system diseases, Dr Sarnarendra Miranpuri said that up to 70% people with diabetes have nervous system damage.

Time is running out and business as usual needs to stop. An interdisciplinary limb salvage team can probably turn the tide of diabetes rates and also make profound impact on quality of life and saving the foot of people with diabetes.

2 comments:

"The team described how they changed the patient care system in the hospital to reach the goals of the St Vincent Declaration, which aimed to reduce the international amputation rate by around 50% over a five-year period. The team began their initiative to reduce the high amputation rate in southwest London through the implementation of a limb salvage service within a multidisciplinary framework. Prior to this, the majority of patients with diabetic foot or critical limb ischaemia were offered angioplasty followed by amputation if healing was unsuccessful. The rates of surgical revascularisation were very low. Furthermore, there was no collaboration between podiatrists, orthopaedic foot specialists, microbiologists and diabetologists, and no clear patient treatment pathway through the hospital. No targets were in place and there was no system for benchmarking the outcomes of the management of the diabetic foot.

Processes were put in place so that every patient with diabetes and critical limb ischaemia would be discussed in a joint forum including microbiologists, diabetologists, orthopaedic foot specialists, podiatrists, tissue viability nurses, vascular technologists, interventional radiologists, plastic surgeons and vascular surgeons.

Every diabetic foot referred to the vascular team is now examined within four hours of referral in daylight hours, and at the start of the working day for out-of-hours referrals. Treatment pathways for these patients are expedited where patients are identified as having a limb at risk. "